The Roberts Anxiety Scale for Elderly

236 Pages·2011·11.37 MB·English

by  Roberts, Margaret Helen

Copyright is owned by the Author of the thesis. Permission is given for
a copy to be downloaded by an individual for the purpose of research and
private study only. The thesis may not be reproduced elsewhere without
the permission of the Author.
The Roberts Anxiety Scale for Elderly:
Development and Psychometric Evaluation

A thesis presented in partial fulfilment
of the requirements for the degree of

Doctor of Clinical Psychology

At Massey University, Albany,
New Zealand

Margaret Helen Roberts (nee Sandham)

2010
Abstract

Psychological literature has clearly expressed the need for a greater understanding
of the phenomenon of anxiety in older adults. In turn, this has contributed to the
validity issues surrounding the measurement of anxiety in older adults using self-
report psychological measures. As such, the need for a new measure of anxiety
specific to older adults has been identified within the literature. This study aimed
to address these issues in two closely related studies. Study one used thematic
analysis to determine the characteristics of anxiety in a sample of 131 community
dwelling older adults. The results supported previous research by indicating that
how older adults experienced worry was of greater importance than the topic of
worry. Social desirability effects were observed in the reporting of anxiety
experiences. Study two developed the content for the Roberts Anxiety Scale for
Elderly (RASE) by combining psychological theory with the results from study one.
The RASE was administered to 203 community dwelling older adults alongside
two existing self-report measures. Confirmatory factor analysis found that a three
factor structure of worry, negative affect, and somatic sensations best accounted
for observed scores on the RASE. Good internal consistency and convergent
validity was found for the RASE. Future research should be directed at evaluating
the performance of the RASE in clinical populations of older adults.
i
Acknowledgements

There are a number of people whom I wish to thank for their generosity in helping
me complete this thesis. Firstly, I wish to thank my family for their love, support,
and generosity during this journey from full time nursing to become a clinical
psychologist. This research would not have been possible without their support.
Also, a special thank you to my husband Bryan for his unwavering confidence in
me, gentle encouragement, and steadfast support during the ups and downs of
research and clinical psychology practicums.
Secondly, I am grateful for the support of my supervisors in helping me
complete this research. To my primary supervisor Dr Richard Fletcher, who
fostered my interest in psychometrics and assisted with the research methodology.
To Dr Jennifer Stillman whose sound judgement, eagle-eyed proof reading, and
encouragement helped keep the momentum of the project. Finally, Associate
Professor Paul Merrick, who inspired this research by expressing the need for a
new measure of anxiety in the elderly, and whose enthusiasm for elderly,
psychological theory, and the research project was infectious.
I also wish to acknowledge the financial support I received from the
Goodman Family Scholarship and the Massey University Vice Chancellors
Scholarship. These scholarships enabled me to focus on my research and produce
a thesis which I hope will benefit the older adult community, and for that I am
grateful.
Finally, I wish to thank the people whom I have met along the way that have
made this journey personally rewarding. I wish to thank the students who have
shared the trials and tribulations of the research process for their humour,
academic support, and friendship. In particular, those students who have joined
me in toiling long hours in the “Interns’ Room” at Massey. I am grateful for the
support of Auckland Greypower, the University of the Third Age (U3A), New
Zealand Motorcaravan Association, and my family and friends for their help in
recruiting participants. Finally, I wish to acknowledge the generosity of the 334
anonymous participants that completed questionnaires to make this research
possible.
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TABLE OF CONTENTS
1 INTRODUCTION ............................................................................................................................................... 1
2 ANXIETY DISORDERS .................................................................................................................................... 4
What is Anxiety? .................................................................................................................................................................4
Common Features of Anxiety ..................................................................................................................................6
Comorbidity of Anxiety Disorders ........................................................................................................................8
Summary...........................................................................................................................................................................8
Hypothesised Tripartite Structure of Anxiety and Depression ..................................................................... 8
Theories on the Aetiology and Maintenance of Anxiety Disorders .......................................................... 11
Psychoanalytic theory ............................................................................................................................................. 11
Behavioural theory ................................................................................................................................................... 12
Cognitive Theories .......................................................................................................................................................... 14
State and Trait Theories ............................................................................................................................................... 14
Diathesis Stress Theory ................................................................................................................................................ 15
Cognitive Model of Anxiety ......................................................................................................................................... 16
The Cognitive Behavioural Five Part Model ........................................................................................................ 17
3 GENERALISED ANXIETY DISORDER ..................................................................................................... 21
Categorical Versus Dimensional Views of DSM-IV Disorders ..................................................................... 21
Summary ............................................................................................................................................................................. 24
Evolution of the GAD Diagnostic Category within the DSM ......................................................................... 24
Cognitive Theories of GAD .......................................................................................................................................... 27
Clark and Beck Cognitive Model of GAD .......................................................................................................... 27
Metacognitive model ................................................................................................................................................ 29
4 ANXIETY IN OLDER ADULTS .................................................................................................................... 34
Epidemiology of Anxiety in Older Adults ............................................................................................................. 34
Why Anxiety may be Experienced Differently in Older Adults ................................................................... 36
Contextual Adult Lifespan Theory ........................................................................................................................... 37
Experiences of Anxiety in Older Adults ................................................................................................................. 41
Somatic experiences ................................................................................................................................................. 41
Behavioural Aspects of Anxiety ........................................................................................................................... 43
Emotional Processes and Expression ............................................................................................................... 44
Difficulties in Researching Anxiety in Older Adults ......................................................................................... 46
Cohort effects ............................................................................................................................................................... 47
DSM-IV ............................................................................................................................................................................ 47
Medical Conditions .................................................................................................................................................... 48
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Communication about Anxiety ............................................................................................................................ 49
Identification of Anxiety Symptoms .................................................................................................................. 49
Future Directions in Researching Anxiety in Older Adults ..................................................................... 50
5 EVALUATING THE VALIDITY OF ASSESSMENT USING PSYCHOLOGICAL MEASURES .................... 53
The Role of Assessment in Clinical Practice ........................................................................................................ 53
Validity ................................................................................................................................................................................. 54
Evaluating Sources of Validity ................................................................................................................................... 55
Content validity .......................................................................................................................................................... 55
Internal Test Structure ............................................................................................................................................ 56
Convergent and Discriminant Validity ............................................................................................................. 57
Factorial Validity ........................................................................................................................................................ 58
Criterion Validity ....................................................................................................................................................... 59
Standardization .......................................................................................................................................................... 59
Consequences of Test Use ...................................................................................................................................... 60
6 VALIDITY EVIDENCE OF PSYCHOLOGICAL MEASURES CURRENTLY IN USE WITH
OLDER ADULTS ................................................................................................................................................... 62
Description of Anxiety Measures in Current Use with Older Adults ........................................................ 62
Description of Measures Developed with Younger Adults ...................................................................... 63
Description of Measures Developed Specifically for Older Adults ...................................................... 63
Measures Referred to in the Validation of Anxiety Measures in Older Adults ............................... 64
Overview of the Validity of Measures in Use with Older Adults ........................................................... 65
Penn State Worry Questionnaire (PSWQ). ..................................................................................................... 65
State-Trait Anxiety Inventory (STAI) ............................................................................................................... 70
Beck Anxiety Inventory ........................................................................................................................................... 74
Hospital Anxiety and Depression Scale (HADS) ........................................................................................... 78
Hamilton Anxiety Rating Scale (HARS) ............................................................................................................ 81
Summary of Findings of Measures Developed in Younger Adults ............................................................ 81
Measures of Anxiety Specifically Developed for use with Older Adults ................................................. 82
The Worry Scale (WS) ............................................................................................................................................. 83
Geriatric Anxiety Inventory (GAI) ...................................................................................................................... 84
Adult Manifest Anxiety Scale- Elderly (AMAS-E)......................................................................................... 86
Short Anxiety Screening Test (SAST) ................................................................................................................ 88
Geriatric Worry Scale (GWS) ................................................................................................................................ 88
Summary of Validity Evidence for Measures Developed for Older Adults ............................................ 89
Summary and Conclusions .......................................................................................................................................... 89
7 OVERVIEW OF CURRENT STUDY
........................................................................................................ 91
Overview of Study One ................................................................................................................................................. 92
Phase One- Clinicians Study .................................................................................................................................. 92
Phase Two- Older Adults ........................................................................................................................................ 93
Overview of Study Two ................................................................................................................................................ 94
Contribution of the Current Study to the Literature ....................................................................................... 95
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8 CHARACTERISING ANXIETY IN OLDER ADULTS QUESTIONNAIRE ANALYSIS
Part One - Clinicians Study ........... 97
........................................................................................................................................... 97
Participants .................................................................................................................................................................. 97
Method ............................................................................................................................................................................ 97
ParCtl iTnwicoia- nCsh aStruadctye Rriesisnuglt As .n..x..i..e..t..y.. .i.n... .O...l.d...e..r.. .A...d...u..l..t.s.. .Q...u...e..s..t..i.o...n..n...a..i..r..e.................................................................. 98
................................................................ 98
Participants .................................................................................................................................................................. 98
Procedure ...................................................................................................................................................................... 99
Characterising Anxiety in Older Adults Questionnaire Results ......................................................... 100
9 CHARACTERISING ANXIETY IN OLDER ADULTS DISCUSSION
...........................................114
Worry topics ................................................................................................................................................................... 114
Physical sensations...................................................................................................................................................... 115
Cognitive symptoms ................................................................................................................................................... 116
Process......................................................................................................................................................................... 116
Content ........................................................................................................................................................................ 116
Emotions .......................................................................................................................................................................... 117
Behaviour ........................................................................................................................................................................ 117
Avoidance behaviour .................................................................................................................................................. 118
Implications for new measure ................................................................................................................................ 120
10 STUDY TWO: THE DEVELOPMENT AND PSYCHOMETRIC EVALUATION OF THE
ROBERTS ANXIETY SCALE FOR ELDERLY
Stage One: Develop a New Psychological Mea .s..u..r..e..................................................................................122
.......................................................................................... 122
StaRgoel eT wofo D: IStMem-I VA nDailaygsnisoses in RASE ................................................................................................................. 124
........................................................................................................................................... 125
Ethics ............................................................................................................................................................................ 125
Participants ............................................................................................................................................................... 125
Psychological Measures ....................................................................................................................................... 127
Procedure ................................................................................................................................................................... 128
Phase One: Data Analysis .................................................................................................................................... 128
Phase Two: Testing and modification of the RASE .................................................................................. 131
Phase Three- Evaluate the Psychometric Properties of the HADS and AMAS-E ........................ 133
Phase Four- Convergent and Discriminant Validity ................................................................................ 134
11 STUDY TWO RESULTS
..........................................................................................................................135
Normality of Data ......................................................................................................................................................... 135
GPhroausep TLwevoe- lR Aenfianley tshise . .R...A...S..E........................................................................................................................................ 135
..................................................................................................................................... 135
Item Level Analysis ................................................................................................................................................ 135
CFA ................................................................................................................................................................................ 136
Final Factor Structure for the RASE ............................................................................................................... 145
Evaluate the Internal consistency of the RASE .......................................................................................... 146
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Phase Four- Evaluation of the AMAS-E and HADS ........................................................................................ 147
Evaluation of the AMAS-E ................................................................................................................................... 147
Evaluation of the HADS ........................................................................................................................................ 152
Phase Five- Convergent Validity............................................................................................................................ 157
12 STUDY TWO DISCUSSION
...................................................................................................................159
Roberts Anxiety Scale for Elderly ......................................................................................................................... 159
Internal Consistency .............................................................................................................................................. 159
Factor Structure ...................................................................................................................................................... 160
Relationship with Study One ............................................................................................................................. 162
Convergent Validity ............................................................................................................................................... 165
Relationship to Psychological Theory ........................................................................................................... 165
Contribution of the Research to the Anxiety in Older Adults’ Literature ...................................... 168
The Hospital Anxiety and Depression Scale ..................................................................................................... 169
Internal Consistency .............................................................................................................................................. 169
Factor Structure ...................................................................................................................................................... 170
Convergent Validity of the HADS ..................................................................................................................... 170
The Adult Manifest Anxiety Scale - Elderly ....................................................................................................... 171
Internal Consistency .............................................................................................................................................. 171
Factor Structure ...................................................................................................................................................... 171
Subscale and Item Content ................................................................................................................................. 171
Revision of the AMAS-E ........................................................................................................................................ 172
Convergent Validity ............................................................................................................................................... 172
Worry severity as measured by the HADS and AMAS-E ............................................................................. 173
Study limitations .......................................................................................................................................................... 174
Future directions .......................................................................................................................................................... 175
Executive summary ..................................................................................................................................................... 176
APPENDIX A
......................................................................................................................................................178
Ethical Approval for Clinicians’ Study................................................................................................................. 178
APPENDIX B
......................................................................................................................................................179
Clinicians’ Questionnaire and Information Sheet .......................................................................................... 179
APPENDIX C
.......................................................................................................................................................181
Study One Ethical Approval ..................................................................................................................................... 181
APPENDIX D
......................................................................................................................................................182
Study one Information Sheet and Questionnaire ........................................................................................... 182
APPENDIX E
.......................................................................................................................................................187
Study Two Ethical Approval .................................................................................................................................... 187
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APPENDIX F
.......................................................................................................................................................188
Letter to Participants from Study One Who Wished to be Contacted for Study Two .................... 188
APPENDIX G
......................................................................................................................................................189
Study Two Questionnaires and Information Sheet ....................................................................................... 189
APPENDIX H
......................................................................................................................................................196
Hypothesised RASE models ..................................................................................................................................... 196
APPENDIX I
........................................................................................................................................................209
Permission to Reprint Questionnaires in Thesis............................................................................................ 209
REFERENCES
.....................................................................................................................................................212

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List of Figures and Tables
TABLES
Table 1. Common Features of Anxiety .............................................................................................................................. 7
Table 2. DSM-IV-TR Criteria for Generalised Anxiety Disorder ......................................................................... 25
Table 3. Internal Consistency and Test-Retest Reliability of the Penn State Worry Questionnaire .. 66
Table 4. Internal Consistency and Test-Retest Reliability of the Penn State
Worry Questionnaire-A ....................................................................................................................................................... 67
Table 5. Convergent and Discriminant Validity for the Penn State Worry Questionnaire ...................... 69
Table 6. Internal Consistency and Test-Retest Reliability of the State Trait Anxiety Inventory ......... 71
Table 7. Convergent and Discriminant Validity of the State Trait Anxiety Inventory .............................. 72
Table 8. Internal Consistency of the Beck Anxiety Inventory ............................................................................. 74
Table 9. Convergent and Discriminant Validity of the Beck Anxiety Inventory ......................................... 76
Table 10. Internal Consistency of the Hospital Anxiety and Depression Scale ............................................ 79
Table 11. Internal Consistency, Test-Retest Reliability, Convergent and Discriminant Validity of the
Worry Scale ............................................................................................................................................................................... 83
Table 12. Summary of the Psychometric Properties of the Geriatric Anxiety Inventory ....................... 85
Table 13. Psychometric Properties of the Adult Manifest Anxiety Scale- Elderly....................................... 87
Table 14. Demographic Information for Characterising Anxiety in Older Adults Study .......................... 99
Table 15. Words Used by Older Adults to Describe Anxiety .............................................................................. 101
Table 16. Topics that Cause Older Adults Worry .................................................................................................... 102
Table 17. Recent Specific Worrying Situation .......................................................................................................... 103
Table 18. Reported Physical Sensations in Recent Worrying Situation ....................................................... 105
Table 19. Reported Thought Process of Older Adults in Recent Worrying Situation ............................. 106
Table 20. Reported Thought Content of Older Adults in Recent Worrying Situation ............................ 107
Table 20. Reported Emotions of Older Adults in Recent Worrying Situation............................................ 108
Table 22. Reported Behaviour of Older Adults in Recent Worrying Situation .......................................... 109
Table 23. Reported Avoidance Behaviour to Reduce Worry ............................................................................. 111
Table 24. How Older Adults Can Tell When Another Older Adult Is Anxious ............................................ 112
Table 25. Correspondence of Own Reported Symptoms with DSM-IV GAD and Depression ............. 113
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